Utilization Review Annual Summary for 2007 Due June 30 for previous calendar year. All health benefit insurers that provide utilization review or have utilization review provided on their behalf shall file an annual summary describing all utilization-review policies and utilization-review monitoring activities, including delegated functions. ORS 743.807, OAR 836-053-1130 1. Company Name: StarPoint Healthcare group 2. Company Address: PO BOX 2339 City, State, ZIP: Missoula MT, 59806-2339 3. Company Web Site: www.abpmtpa.com 4. Name, e-mail address, and phone number of the person completing this form: Jayne Hanich RN, jhanich@starpointmedical.com PO Box 2339, Missoula MT 59806-2339, Ph. 406-532-1502. 5. Name, title, and department of manager responsible for oversight of utilization review: Jayne Hanich RN, Manager of Care Management Services at StarPoint Healthcare Group 6. Time frame for making utilization review decisions: Target: Our target deadlines are those provided by the DoL for Utilization Management. The following are the DoL guidelines that we adhere to so that we can maintain our URAC accreditation. • Prospective Review-Urgent: As soon as possible, but no later than 72 hours of receipt of the request • Prospective Review-Non Urgent: Within 15 calendar days • Concurrent Review: Urgent and received within at least 24 hours before certification expires: Within 24 hours of the request • Concurrent Review: Non urgent and received at least 24 hours before certification expires: within 72 hours of receipt of the request • Concurrent Review: Urgent or Non-urgent and received less than 24 hours before certification expires: Within 72 hours of request • Retrospective Review: Within 30 calendar days of the request. (This period may be extended one time by the organization for up to 15 days under specific provisions consistent with DoL rules). Actual: (Average) Well over 90% of our decisions are made the same day of the re quest. None exceed 72 hours and those are not urgent in nature. The Decision Time Line Report that exists within our software system verifies this information. It was run for the following time frame and can be reproduced at any time: 01-01-2007 thru 1231-2007 Filing Date: 7-1-08
URL or the publication title, date, and page: Accreditation Program Guide for Health Utilization Management Standards, Version 4.2 URAC 2002. Page 133 7. Specify minimum qualifications for those who make first level utilization review decisions: We employ only currently licensed in Montana RNs. They must have at least 2 years of experience in medical/surgical, rehabilitation, psychiatric, or emergency services, and/or certification review experience: comparable to out patient experience. In addition, they are required to have additional research, organizational and communication skills and be able to multi-task. URL or the publication title, date, and page: StarPoint Healthcare Group Position Summary: Utilization Management Nurse Reviewer, current as of this date and pages 1 and 2. 8. Specify minimum qualification for those who make second level utilization review decisions: If the RN Nurse Reviewer is unable to approve days, the review is sent electronically to our Medical Director. The Medical Director is required to have an unrestricted and current license to practice medicine as a MD or DO in the state of Montana, and he/she must have Board Certification in their respective specialty. Additionally, he/she must have at least 3 years of post graduate experience in direct patient care, have excellent oral and written communication skills and maintain malpractice insurance. URL or the publication title, date, and page: StarPoint Healthcare Group Position Summary: Medical Director. Current to date. Pages 1 and 2. 9. Do Providers participate in making utilization review decisions? Yes. At which levels: Providers (Attending physician/provider) participate at the 2nd level of the review process. Our Nurse Reviewers are not allowed to issue denial decisions with the exception of those for lack of information. Our Medical Director is, likewise, not allowed to issue a medical necessity denial without attempting contact with the attending provider. The URAC approved policy at StarPoint Healthcare Group requires that our Medical Director/Health care Advisor (HCA) make 2 attempts in 2 working days to reach the treating provider by phone. If the treating provider is unavailable on one or more of those days, this time may be extended by 24 hours, but should in no case exceed 3 calendar days in order to affect a timely review. If needed medical information is not available or is not adequate or if the HCA is unable to accomplish the Peer to Peer after 2 attempts in 2 working days, the HCA may issue a denial for lack of information. URL or the publication title, date, and page: StarPoint Healthcare Group Utilization Management Policies and Procedures: Peer Review. Page 4. 11-17-2007 10. Indicate the sources of clinical information the company researches for utilization review decisions: The initial tool is the Ad Hoc Addendum to the Guidelines which takes into consideration a reasonable and conservative length of stay for particular conditions or procedures not covered by the Milliman USA Optimal Recovery Guidelines. As Milliman builds its guidelines and they become more robust, this tool is used less
frequently. It does, however, take into consideration the standard of practice in our geographic locality so some are still in use today. The initial conservative length of stay can be approved by using the Ad hoc Adendum and then further days will be subject to continued stay or concurrent review. Our second and, by far, most used guideline is the Milliman USA Optimal Recovery Guideline which is nationally approved, updated annually and used by many review companies in the USA today. If the nurse reviewer is unable to find a guideline in this resource, she/he may reference the Solucient Length of Stay Guideline which takes into consideration the member’s age, number of co morbid factors and assigns a length of stay according to the procedure being done. Finally, we have in house Assessment Tools built off of the Medicare Guidelines for skilled Nursing and rehabilitation reviews. We use the Milliman USA Optimal Recovery Guideline for our psychiatric admissions. The American Society of Addiction Medicine Criteria is used for reviewing our chemical dependency reviews. The nurses are not allowed to deny based on medical necessity. If unable to approve days based on one of the above criteria sets, the review will be forwarded to our Medical Director/HCA. URL or the publication title, date, and page: StarPoint Utilization Management Policies and Procedures: Criteria. 11-16-2007 Pages 1,2 and 3. 11. List company’s steps in developing utilization review criteria: All criteria are reviewed by our staff of nurses and our Medical Director/HCA on an annual basis per the requirements of URAC, our national accreditation entity. If there should be a request to add something to the Ad Hoc Addendum or one of the Assessments, that request will be reviewed by the Medical Director/HCA at the time of the request. These types of requests are few and far between. However, if necessary, we have a process in place that required the review of a medical expert prior to use. We contract for use of nationally approved criteria/guideline sets and undergo review and training on the use of them on an annual basis or whenever updates are made to the guidelines. This is the case with Milliman USA. We purchase new ASAM and Solucient criteria sets whenever they are made available by their developing companies. URL or the publication title, date, and page: StarPoint Healthcare Group Utilization Management Policies and Procedures: Criteria. 11-16-2007 12. What action or event causes utilization review criteria to be revised? For the most part the event that leads to review is timeline related. All criteria are reviewed on an annual basis per the URAC accreditation requirement. Annual training for use of updated or new criteria/guideline sets is conducted by trainers provided by Milliman USA which is the main guideline used by StarPoint Healthcare Group. We update our ASAM and Solucient Criteria as they are updated by the developing companies. As these nationally recognized criteria/guidelines become more robust, we have fewer and fewer requests to add to the in house assessments or the Ad Hoc Adendum. There were no requests for changes in 2007. URL or the publication title, date, and page: StarPoint Healthcare Group Utilization Management Policies and procedures: Criteria. 11-16-2007 Pages 2 and 3.
13. How does the company inform enrollees about changes in utilization review criteria? We do not perform this process however copies of the criteria used if a denial is issued are available upon request. URL or the publication title, date, and page: StarPoint Healthcare Group Utilization Management Policies and Procedures: Certification Denial. 11-19-2007 Page 7 14. How does the company inform providers about changes in utilization review criteria? We do not perform this process however copies of the criteria used if a denial is issued are available upon request. URL or the publication title, date, and page: StarPoint Healthcare Group Utilization Management Policies and Procedures: Certification Denial. 11-19-2007 Page 7 15. Is there a procedure for monitoring in-house utilization review criteria? Yes. Specify: As noted above, Starpoint Healthcare Group Utilization Management Policies and Procedures address this in the policy related to “Criteria”. URL or the publication title, date, and page: StarPoint Healthcare Group Utilization Management Policies and Procedures: Criteria. 11-16-2007 pages 1, 2, and 3 16. Does the company delegate any utilization review activities to outside resources? No. Specify: NA URL or the publication title, date, and page: NA 17. Are there procedures for monitoring utilization review activities delegated to outside resources? No. Specify: None of our utilization review activities are delegated to outside resources. URL or the publication title, date, and page: NA